Antithrombotic Therapy for Peripheral Revascularisation

2020 ◽  
Vol 18 (3) ◽  
pp. 223-236
Author(s):  
Marco De Carlo ◽  
Marco Angelillis ◽  
Riccardo Liga
Keyword(s):  
Lower Extremity ◽  
Coagulation Cascade ◽  
Limb Amputation ◽  
Antiplatelet Treatment ◽  
Risk Factor Modification ◽  
Public Health Burden ◽  
Surgical Revascularisation ◽  
Anticoagulant Drugs ◽  
Depth Analysis ◽  
Artery Disease

: Lower extremity artery disease (LEAD) represents a major public health burden, affecting hundreds of millions of people worldwide. Although risk-factor modification, exercise training and medical treatment are the mainstays of the management of LEAD, endovascular or surgical revascularisation is recommended when there is the risk of limb amputation and when drug-resistant claudication severely affects patient lifestyle. Over recent years, the number of peripheral vascular interventions (PVI) has soared worldwide, driven by the improvements in endovascular techniques and devices. This growth was accompanied by a large number of clinical trials aimed at assessing the safety and efficacy of the various revascularisation modalities, while very little evidence was collected regarding the best antithrombotic treatment in patients undergoing peripheral revascularisation. In particular, considering the extensive length of diseased vessels usually treated in PVI, an optimised approach to both platelet function and coagulation cascade is of paramount importance. However, the role of antiplatelet and anticoagulant drugs following lower extremity revascularisation is largely extrapolated from the coronary field. Current guidelines recommend long-term single antiplatelet treatment for the majority of both endovascular and surgical revascularisation procedures, preceded by an initial short-term dual antiplatelet treatment in case of PVI. : We present an overview of the indications and techniques of both endovascular and surgical peripheral revascularisation, followed by an in-depth analysis of the available evidence regarding type and duration of antiplatelet and anticoagulant treatment following revascularisation.

Diabetes Mellitus And Outcomes Of Lower Extremity Revascularization For Peripheral Artery Disease

2020 ◽  
Author(s):  
Nipun Bhandari ◽  
Jonathan D Newman ◽  
Jeffrey S Berger ◽  
Nathaniel R Smilowitz
Keyword(s):  
Diabetes Mellitus ◽  
Lower Extremity ◽  
Peripheral Artery Disease ◽  
Hospital Readmission ◽  
Organ Damage ◽  
Limb Amputation ◽  
Peripheral Artery ◽  
Artery Disease ◽  
The Impact ◽  
Lower Extremity Revascularization

Abstract Introduction The impact of diabetes mellitus (DM) on outcomes of lower extremity revascularization (LER) for peripheral artery disease (PAD) is uncertain. We characterized associations between DM and post-procedural outcomes in PAD patients undergoing LER. Methods Adults undergoing surgical or endovascular LER were identified from the 2014 Nationwide Readmissions Database. DM was defined by ICD-9 diagnosis codes and sub-classified based on the presence or absence of complications (poor glycemic control or end-organ damage). Major adverse cardiovascular and limb events (MACLE) were defined as the composite of death, myocardial infarction, ischaemic stroke, or major limb amputation during the index hospitalization for LER. For survivors, all-cause 6-month hospital readmission was determined. Results Among 39,441 patients with PAD hospitalized for LER, 50.8% had DM. The composite of MACLE after LER was not different in patients with and without DM after covariate adjustment, but patients with DM were more likely to require major limb amputation (5.5% vs. 3.2%, p < 0.001; adjusted odds ratio [aOR] 1.22, 95% CI 1.03-1.44) and hospital readmission (59.2% vs. 41.3%, p < 0.001; aOR 1.44, 95% CI 1.34-1.55). Of 20,039 patients with DM hospitalized for LER, 55.7% had DM with complications. These patients were more likely to have MACLE after LER (11.1% vs. 5.2%, p < 0.001; aOR 1.56 95% CI 1.28-1.89) and require hospital readmission (61.1% vs. 47.2%, p < 0.001; aOR 1.41 95% CI 1.27-1.57) than patients with uncomplicated DM. Conclusions DM is present in ≈50% of patients undergoing LER for PAD and is an independent risk factor for major limb amputation and 6-month hospital readmission.

scholarly journals The role of prognostic nutritional index in predicting amputation in patients with lower extremity peripheral artery disease

2021 ◽  
Vol 13 (1) ◽  
pp. 43-48
Author(s):  
Hilal Erken Pamukcu ◽  
Hamza Sunman ◽  
Alperen Taş ◽  
Mert Aker ◽  
Haluk Furkan Şahan ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Nutritional Status ◽  
Lower Extremity ◽  
Peripheral Artery Disease ◽  
Wide Spectrum ◽  
Prognostic Nutritional Index ◽  
Limb Amputation ◽  
Peripheral Artery ◽  
Nutritional Index ◽  
Artery Disease

Introduction: Lower-extremity peripheral artery disease (PAD) can lead to a wide spectrum of symptoms that can progress from claudication to amputation. The prognostic nutritional index (PNI), which is calculated using the levels of albumin and lymphocyte, is an accepted indicator of immunological and nutritional status. In this study, the association between nutritional status determined using the PNI, and extremity amputation in patients with lower-extremity PAD was investigated. Methods: Lower-extremity PAD patients who had been admitted to the cardiology clinic of the Dışkapı Yıldırım Beyazıt Training & Research Hospital with stage 2b or higher claudication, and who were technically unsuitable for revascularization or underwent unsuccessful revascularization procedure were enrolled in this retrospective study. Patients were grouped according to whether or not limb amputation had been performed previously. Potential factors were tested to detect independent predictors for amputation with logistic regression analysis. Results: A study group was formed with 266 peripheral artery patients. The amputated group (39 patients) had a higher number of hypertensive (76.9% vs 57.7%; P = 0.032) and diabetic (92.3% vs 54.2%; P <0.001) patients than those in the non-amputated group (227 patients). The median PNI value of the amputated group was lower than that of the non-amputated group (31.8 vs 39.4; P <0.001). Multivariate logistic regression showed that the PNI (OR: 0.905, 95% CI: 0.859 – 0.954; P <0.001) was independently related with amputation. Conclusion: Immune-nutritional status based on PNI was independently associated with limb amputation in patients with lower-extremity PAD.

Activated Factor VII–Antithrombin Complex Plasma Concentration Is An Independent Predictor Of Total and Cardiovascular Mortality In Patients With Coronary Artery Disease and Its Prognostic Significance Is Improved By Using Factor VII Genotype-Specific Threshold Levels

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2339-2339
Author(s):  
Nicola Martinelli ◽  
Domenico Girelli ◽  
Marcello Baroni ◽  
Patrizia Guarini ◽  
Federica Tosi ◽  
...  
Keyword(s):  
Plasma Concentration ◽  
Cardiovascular Mortality ◽  
Promoter Polymorphism ◽  
Coagulation Cascade ◽  
Factor Vii ◽  
Threshold Levels ◽  
Activated Factor Vii ◽  
Anticoagulant Drugs ◽  
Study Population ◽  
Artery Disease

Abstract Introduction Plasma concentration of activated factor VII (FVIIa)-antithrombin (AT) complex has recently been proposed as a marker of intravascular exposure of tissue factor (TF) and, thus, of activation of the extrinsic pathway of coagulation cascade. However, the results of studies investigating the potential relationship between FVIIa-AT complex and coronary artery disease (CAD) are only preliminary so far. The aim of this study was to investigate the predictive value of FVIIa-AT plasma concentration for total and cardiovascular mortality in the setting of secondary prevention of CAD. Methods Within the framework of the Verona Heart Study (VHS), we selected a cohort of 510 patients with angiographically proven CAD (mean age 61.8±10.6 years; females 23.7%), who were not taking anticoagulant drugs at time of enrolment and for whom plasma citrate samples for FVIIa-AT assay were available. These patients were prospectively followed for a median period of 64 months. Plasma concentration of FVIIa-AT complex was determined by ELISA. Moreover, patients were genotyped for FVII -323 del/ins (A1/A2) promoter polymorphism. Results The majority of patients had severe CAD and received surgical or endovascular coronary revascularization during the period 1999–2006 (81.8%). Eight patients had peri-operative deaths and were excluded from subsequent analyses. During follow-up, 105 (20.9%) subjects died, with 68 (13.5%) events attributed to cardiovascular causes. CAD patients who died had a significantly higher plasma concentration of FVIIa-AT than those survived (P=0.002). Stratifying the study population on the basis of the FVIIa-AT quartiles, we noted an evident increase of both total and cardiovascular mortality for the subjects in the two upper quartiles (Figure 1A). CAD patients with plasma concentration of FVIIa-AT higher than the median value (79 pM) had an increase in both total and cardiovascular mortality than those with lower values (26.7% versus 15.0%, P=0.001, and 17.3% versus 9.7%, P=0.006 by Log Rank tests, respectively). After adjustment for the other predictors of mortality at univariate analysis (i.e. sex, age, number of coronary vessels involved, MI history, hypertension, diabetes, BMI, renal function, and hs-CRP concentration), elevated FVIIa-AT (≥79 pM) significantly predicted both total and cardiovascular mortality (HR for total and cardiovascular mortality: 2.24 (1.35-3.70) and 1.92 (1.02-3.61), respectively). Such associations remained significant also after adjustment for left ventricular ejection fraction (HR for total and cardiovascular mortality: 1.91 (1.21-3.03) and 1.86 (1.03-3.34), respectively), as well as for the main cardiovascular therapies at discharge, like beta-blockers, ACE-inhibitors, statins, and antiplatelet/anticoagulant drugs (HR for total and cardiovascular mortality: 1.67 (1.08-2.59) and 1.77 (1.01-3.11), respectively). In a subgroup of subjects for whom data of FVIIa were available (n=191), FVIIa-AT concentration remained significantly associated with mortality, while FVIIa levels had no prognostic role. The FVII -323 del/ins (A1/A2) promoter polymorphism is well know to be associated with FVII/FVIIa levels. The A2 allele, that results in a decrease of FVIIa levels, was consistently associated with lower FVIIa-AT plasma concentration in our study-population (71.5 pM in A2 carriers versus 89.3 pM in A1A1 homozygous carriers, P<0.001 by t-test). Remarkably, the predictive model of FVIIa-AT plasma concentration appeared to be improved when stratified on the basis of FVII genotype-specific threshold levels (Figure 1B - HR 2.57 (1.36-4.85) comparing the highest versus the lowest quartile according genotype-specific thresholds, while the HR was 1.95 (1.07-3.53) according whole population thresholds). Conclusions In this study high plasma concentrations of FVIIa-AT complex were an independent predictor of both total and cardiovascular mortality in patients with angiographically demonstrated CAD, speculatively reflecting a prothrombotic diathesis due to TF-related activation of coagulation cascade. Moreover, the predictive model appeared to be improved by using FVII genotype-specific threshold levels of FVIIa-AT concentration, addressing the interest on TF-related pathways. In summary, FVIIa-AT plasma concentration may be a useful prognostic marker in the setting of secondary prevention of CAD. Disclosures: No relevant conflicts of interest to declare.

Antithrombotic Therapy in Lower Extremity Artery Disease

2020 ◽  
Vol 18 (3) ◽  
pp. 215-222 ◽  
Author(s):  
Mislav Vrsalovic ◽  
Victor Aboyans
Keyword(s):  
Lower Extremity ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Cardiovascular Outcomes ◽  
Lower Limbs ◽  
Stent Type ◽  
Increased Risk ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

scholarly journals Retraction Note: Association of severity of coronary artery disease by SYNTAX score (SS) and lower extremity arterial disease by duplex ultrasound (DUS) study—an Indian perspective

2020 ◽  
Vol 72 (1) ◽  
Author(s):  
Saumen Nandi ◽  
Anindya Mukherjee ◽  
Dibbendhu Khanra ◽  
Kaushik Biswas
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Lower Extremity ◽  
Duplex Ultrasound ◽  
Arterial Disease ◽  
Syntax Score ◽  
Lower Extremity Arterial Disease ◽  
Retraction Notice ◽  
Artery Disease ◽  
Indian Perspective

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s43044-020-00091-z.

scholarly journals Molecular Mechanisms Associated with ROS-Dependent Angiogenesis in Lower Extremity Artery Disease

Antioxidants ◽  
2021 ◽  
Vol 10 (5) ◽  
pp. 735
Author(s):  
Greg Hutchings ◽  
Łukasz Kruszyna ◽  
Mariusz J. Nawrocki ◽  
Ewa Strauss ◽  
Rut Bryl ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Blood Vessel ◽  
Lower Extremity ◽  
Molecular Mechanisms ◽  
Lower Extremities ◽  
Tissue Response ◽  
Peripheral Arteries ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Currently, atherosclerosis, which affects the vascular bed of all vital organs and tissues, is considered as a leading cause of death. Most commonly, atherosclerosis involves coronary and peripheral arteries, which results in acute (e.g., myocardial infarction, lower extremities ischemia) or chronic (persistent ischemia leading to severe heart failure) consequences. All of them have a marked unfavorable impact on the quality of life and are associated with increased mortality and morbidity in human populations. Lower extremity artery disease (LEAD, also defined as peripheral artery disease, PAD) refers to atherosclerotic occlusive disease of the lower extremities, where partial or complete obstruction of peripheral arteries is observed. Decreased perfusion can result in ischemic pain, non-healing wounds, and ischemic ulcers, and significantly reduce the quality of life. However, the progressive atherosclerotic changes cause stimulation of tissue response processes, like vessel wall remodeling and neovascularization. These mechanisms of adapting the vascular network to pathological conditions seem to play a key role in reducing the impact of the changes limiting the flow of blood. Neovascularization as a response to ischemia induces sprouting and expansion of the endothelium to repair and grow the vessels of the circulatory system. Neovascularization consists of three different biological processes: vasculogenesis, angiogenesis, and arteriogenesis. Both molecular and environmental factors that may affect the process of development and growth of blood vessels were analyzed. Particular attention was paid to the changes taking place during LEAD. It is important to consider the molecular mechanisms underpinning vessel growth. These mechanisms will also be examined in the context of diseases commonly affecting blood vessel function, or those treatable in part by manipulation of angiogenesis. Furthermore, it may be possible to induce the process of blood vessel development and growth to treat peripheral vascular disease and wound healing. Reactive oxygen species (ROS) play an important role in regulation of essential cellular signaling pathways such as cell differentiation, proliferation, migration and apoptosis. With regard to the repair processes taking place during diseases such as LEAD, prospective therapeutic methods have been described that could significantly improve the treatment of vessel diseases in the future. Summarizing, regenerative medicine holds the potential to transform the therapeutic methods in heart and vessel diseases treatment.

Relationship of triglyceride–glucose index with chronic limb-threatening ischemia in lower extremity peripheral artery disease

Vascular ◽  
2021 ◽  
pp. 170853812110183
Author(s):  
Arda Aybars Pala ◽  
Yusuf Salim Urcun
Keyword(s):  
Lower Extremity ◽  
High Density Lipoprotein ◽  
Peripheral Artery Disease ◽  
Density Lipoprotein ◽  
Peripheral Artery ◽  
Tyg Index ◽  
Triglyceride Glucose Index ◽  
Group 2 ◽  
Artery Disease ◽  
Group 1

Objectives Triglyceride-glucose index (TyG index), which is defined as the simple and novel marker of insulin resistance, is becoming increasingly important as a promising predictive marker for atherosclerotic diseases. Chronic limb-threatening ischemia is defined as the most advanced stage of the lower extremity peripheral artery disease, whose main cause is atherosclerosis and is associated in this respect with amputation, impaired quality of life, and mortality. The main purpose of the present study was to investigate the relation between the calculated TyG index values and chronic limb-threatening ischemia development. Methods A total of 296 patients who were diagnosed with lower extremity peripheral artery disease in our outpatient clinic between October 2018 and October 2020 were included in this study retrospectively. Two groups were formed by clinically staging the patients according to Rutherford Classification. Patients who did not develop chronic limb-threatening ischemia were classified as “Group 1” ( n = 224) and those who developed were classified as “Group 2” ( n = 72). Results The mean TyG index values that were calculated in Group 2 were significantly higher than in Group 1 (9.27 ± 0.31 vs. 9.00 ± 0.34, p < 0.001). In the multivariate logistic regression analysis conducted to determine the predictors of chronic limb-threatening ischemia development, C-reactive protein (OR [Odds Ratio]: 1.220, 95% CI [confidence interval]: 1.092–1.363, p < 0.001), high-density lipoprotein cholesterol (OR: 0.775, 95% CI: 0.715–0.839, p < 0.001) and TyG index (OR: 5.796, 95% CI: 2.050–16.382, p = 0.001) were identified as independent predictors. Receiver operating characteristic analysis revealed that the cut-off value of TyG index was 9.13 (area under the curve: 0.721, p < 0.001) with 70.8% sensitivity and 65.2% specificity. The TyG index was significantly correlated with Rutherford category, high-density lipoprotein cholesterol and mean platelet volume. Conclusions Chronic limb-threatening ischemia development may be predicted with the TyG index value, which is calculated easily from routine biochemical parameters, in patients diagnosed with lower extremity peripheral artery disease.

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